PDC_2007_Intensive Care Design

1. Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCM
Washington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHA
HKS Inc.
Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 1
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 1
Debajyoti Pati, PhD AIIA
HKS Inc.
Dallas, Texas

2. Outline
• A Day in the Life on the Unit
• Critical Care Teams
• Demand / SupplyDemand / Supply
• Expectations Needs
E i t f C• Environment of Care
• Constraining Forces
• Guidelines Minimalism
• Evolving Trends / Predictions / Future
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 2
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 2
Evolving Trends / Predictions / Future
• The Ideal Room

3. Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCM
Washington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHA
HKS Inc.
Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 3
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 3
Debajyoti Pati, PhD AIIA
HKS Inc.
Dallas, Texas

4. Shadowing Studyg y
• Washington Hospital CenterWashington Hospital Center
• Two critical care units – SICU and CCU
• Shadowing: MD Intensivist, RN, Unit Clerk
• 6-Hour Period: 7 am to 1 pm• 6-Hour Period: 7 am to 1 pm
• HKS Researchers: RN, RRT, PhD Arch
• 2-Hour shadowing rotation
• RN staffing ratios: SICU 2:1 / CCU 1:1
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 4
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 4
• RN staffing ratios: SICU-2:1 / CCU-1:1

5. Washington Hospitalg
CC
CCUCCU SICUSICU
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 5
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 5
1990’s
11 Beds
1990’s
11 Beds
1970’s
14 Beds
1970’s
14 Beds

6. MD Intensivist Time
LOCATION ACTIVITY
75%
LOCATION
37% Roomside Station
18% Corridor
ACTIVITY
33% Consultation
19% Info Gathering
83%
75%18% Corridor
18% Patient Bedside
12% Off Unit
19% Info Gathering
16% Reporting
15% Document / OE
10%
7% Lounge (Birthday!)
3% Central Station
6% Procedures
5% Break
3% Consult Room
1% Conf Room
4% Patient Care
1% Phone Call
1% Searching
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 6
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 6
1% Searching
0% Hand Washing

7. SICU vs CCU RN Time
LOCATION ACTIVITY
SICU CCU
76 -27% Patient Room
8 -20% Central Station
SICU CCU
34 -45% Patient Care
20 -28% Documentation8 -20% Central Station
7 - 1% Med Room
5 -20% Roomside Station
20 -28% Documentation
13 - 5% Consultation
8 - 1% Medications
2 - 5% Corridor
1 -14% Patient Toilet
1 11% Lounge
6 - 3% Procedures
6 - 0% Reporting
4 0% Phone1 -11% Lounge
0 - 2% Nourish Room
4 - 0% Phone
4 - 3% Searching
3 - 4% Socializing
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 7
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 7
g
1 - 1% Hand Washing
1 -10% Eating

8. SICU vs CCU Unit Clerk Time
ACTIVITYLOCATION ACTIVITY
SICU CCU
28 -19% Phone
LOCATION
SICU CCU
71 -69% Central Station 8 9% o e
26 -42% Documentation
21 - 6% Socializing
69% Ce t a Stat o
13 -13% Off Unit
10 -13% Break Room g
9 - 6% Consulting
9 -16% Eating
4 - 3% Corridor
1 - 0% Roomside Station
3 - 9% Search/Gathering
3 - 0% Relaxing
1 - 0% Staff Toilet
0 - 2% Nourishment Room
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 8
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 8
1 - 2% Organizing25 - 33% impacts nurses!

9. Posture (Ergonomic Interest)
NURSEPHYSICIAN CLERKNURSE
SICU CCU
0 - 3% Bending
PHYSICIAN
0% Bending
CLERK
SICU CCU
0 - 0% Bending0 3% Bending
3 - 0% Squatting
0 -13% Leaning
0% Bending
0% Squatting
0% Leaning
0 0% Bending
0 - 0% Squatting
0 - 0% Leaning0 13% Leaning
0 - 0% Reaching
4 -36% Sitting
g
0% Reaching
56% Sitting
0 0% Leaning
2 - 0% Reaching
79 -77% Sittingg
92 -56% Standing
1 - 5% Walking
41% Standing
0% Walking
g
19 -23% Standing
0 - 0% Walking
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 9
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 9

10. Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCM
Washington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHA
HKS Inc.
Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 10
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 10
Debajyoti Pati, PhD AIIA
HKS Inc.
Dallas, Texas
© HKS 2007

11. Rooms
Lav/
ToiletCare Zone 3
16 ‘ gross
IV
Pumps
Physio
Monitors
Utility Boom
@ Ceiling
Toilet
Waste
Zone
Dialysis
Machine
Overbed
TableCare
Zone21’
Care
Zone
1
Balloon
Pump
M/S
Supply
Cart
Hypothermia
Unit
Family
Zone
Zone
2
21
gross
Data Entry/
Access
A
320 f
A
320 f
Sleeper
Chair
Data Entry/
Hand
Washing
Sink
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 11
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 11
320 nsf320 nsf
y
Access
© HKS 2007

12. Rooms
Lav/
Toilet
Care Waste
16 ‘ gross
Physio
Monitors
Utility Boom
@ Ceiling
Toilet
Zone
3
Waste
Zone
Dialysis
Machine
IV
Pumps Overbed
Table
Care
Zone
1
Care21’
Balloon
Pump
M/S
Supply
Cart
Data Entry/
Access
Hypothermia
UnitFamily
Zone
Care
Zone
2
21
gross
BB
Sleeper
Chair
Hand
Washing
Sink
Data Entry/
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 12
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 12
320 nsf320 nsf
y
Access

13. Rooms
Lav/
Toilet
C
Waste
18’ gross
Toilet
Care
Zone
1
Care
Waste
Zone
Balloon
Pump
Physio
Monitors
Zone
3
21’ IV
Utility Boom
@ Ceiling
Hypothermia
Unit
Overbed
Table
Data Entry/
Access
Family
Zone
Care
Zone
2
21
gross
Dialysis
Machine
Pumps
@ Ce g
M/S
Supply
Cart
CC
Sleeper
Chair
Hand
Washing
Sink
Data Entry/
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 13
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 13
360 nsf360 nsf
y
Access

14. Rooms
Lav/
Toilet
Waste
18’ gross
Sl Toilet
Care
Zone
2
Waste
Zone
Dialysis
Machine
IV
Pumps
Family
Zone
Sleeper
Chair
Care
Zone
321’
Utility Boom
@ Ceiling
Hypothermia
Unit
Pumps
Overbed
Table
o e
Data Entry/
Access
Care
Zone
21
gross Balloon
Pump
Physio
Monitors
M/S
Supply
Cart
DD
Hand
Washing
Sink
Data Entry/
1
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 14
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 14
360 nsf360 nsf
y
Access

15. Toward an Ideal Room Idea
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 15
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 15

16. BedBed
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 16
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 16© HKS 2007

17. BedBed
Equipment
Pumps &
Monitors
IT
Cart
Overbed
T bl
Ventilator
Balloon
Pump
TableDialysis
Machine
Hypothermia
Unit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 17
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 17© HKS 2007

18. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Pumps &
Monitors
IT
Cart
Overbed
T bl
Ventilator
Balloon
Pump
TableDialysis
Machine
Line TraysLine Trays Hypothermia
Unit
Line Trays
Along
Bedsides
Line Trays
Along
Bedsides
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 18
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 18© HKS 2007

19. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Circle of Access
Pumps &
Monitors
16’
dia
Rolling
Stock for
Work Surface
And Supplies
Rolling
Stock for
Work Surface
And Supplies
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
And SuppliesAnd Supplies
Balloon
Pump
TableDialysis
Machine
Hypothermia
Unit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 19
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 19© HKS 2007

20. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Circle of Access
Staff / Physicians
Pumps &
Monitors
16’
dia
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
Balloon
Pump
TableDialysis
Machine
Hypothermia
Unit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 20
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 20© HKS 2007

21. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Circle of Access
Staff / Physicians
Imaging
Pumps &
Monitors
16’
dia
M/S
Supply
Cart
Overbed
T bl
Ventilator
Portable
X-Ray
Balloon
Pump
Table
Hypothermia
Unit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 21
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 21© HKS 2007

22. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Circle of Access
Staff / Physicians
Imaging
Pumps &
Monitors
16’
dia
Procedures
M/S
Supply
Cart
Ventilator
Portable
C-Arm
Monitor
Balloon
Pump
Hypothermia
Unit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 22
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 22© HKS 2007

23. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Pumps &
Monitors
16’
dia
Circle of Access
Staff / Physicians
Imaging
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
Procedures
Lines of Sight
Balloon
Pump
TableDialysis
Machine
Hypothermia
Unit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 23
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 23© HKS 2007

24. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Pumps &
Monitors
16’
dia
Circle of Access
Staff / Physicians
Imaging
Toilet
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
Procedures
Lines of Sight
Work Areas
Balloon
Pump
Data Entry/
Access
TableDialysis
Machine
Work Areas
Hypothermia
Unit
Data Entry/
Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 24
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 24© HKS 2007

25. Bed Toilet
Bed
Equipment
Power / Linkages
Toilet
DeskCloset Couch
Pumps &
Monitors
Pumps &
Monitors
16’
dia
Circle of Access
Staff / Physicians
Imaging
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
Procedures
Lines of Sight
Work Areas
Balloon
Pump
Data Entry/
Access
TableDialysis
Machine
Work Areas
Family Areas
Hypothermia
Unit
Data Entry/
Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 25
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 25© HKS 2007

26. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Pumps &
Monitors
16’
dia
Circle of Access
Staff / Physicians
Imaging
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
Procedures
Lines of Sight
Work Areas
Balloon
Pump
Data Entry/
Access
TableDialysis
Machine
Work Areas
Family Areas
Consult / Education
Hypothermia
Unit
Data Entry/
Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 26
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 26© HKS 2007

27. BedBed
Equipment
Power / Linkages
Pumps &
Monitors
Pumps &
Monitors
16’
dia
Circle of Access
Staff / Physicians
Imaging
Swing
Away
Privacy
Swing
Away
Privacy
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
Procedures
Lines of Sight
Work Areas
Privacy
Screen
Privacy
Screen
Balloon
Pump
Data Entry/
Access
TableDialysis
Machine
Work Areas
Family Areas
Consult / Education
Hypothermia
Unit
Data Entry/
Access
Room Enclosure
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 27
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 27© HKS 2007

28. BedBed
Equipment
Power / Linkages
AccessAccess
Pumps &
Monitors
Pumps &
Monitors
16’
dia
Circle of Access
Staff / Physicians
Imaging
without
moving
Bed!
without
moving
Bed!
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
23’
gross
Procedures
Lines of Sight
Work Areas
Balloon
Pump
Data Entry/
Access
TableDialysis
Machine
Work Areas
Family Areas
Consult / Education
Hypothermia
Unit
Data Entry/
Access
Room
Critical Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 28
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 28
18’
gross© HKS 2007

29. BedBed
Equipment
Power / Linkages
Circle of Access
Staff / Physicians
Imaging
Pumps &
Monitors
Pumps &
Monitors
16’
dia
Procedures
Lines of Sight
Work Areas
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
23’
gross
23’
gross
Work Areas
Family Areas
Consult / Education
Balloon
Pump
Data Entry/
Access
TableDialysis
Machine
Room
Critical Access
Patient View
Hypothermia
Unit
Data Entry/
Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 29
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 29
18’
gross
18’
gross
Patient view outside via
mirrors on furr-down
Patient view outside via
mirrors on furr-down
© HKS 2007

30. BedBed
Equipment
Power / Linkages
LCD panel
in ceiling
projecting
LCD panel
in ceiling
projecting
Circle of Access
Staff / Physicians
Imaging
Pumps &
Monitors
Pumps &
Monitors
p j g
family
photos or
favorite
images
p j g
family
photos or
favorite
images
Procedures
Lines of Sight
Work Areas
M/S
Supply
Cart
IT
Cart
Ventilator imagesimages
Work Areas
Family Areas
Consult / Education
Balloon
Pump
Data Entry/
Access
Dialysis
Machine
Room
Critical Access
Patient View
Hypothermia
Unit
Data Entry/
Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 30
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 30
Focused Imagery
© HKS 2007

31. Toilet
DeskCloset Couch
Pumps &
Monitors
Pumps &
Monitors
16’
dia
M/S
Supply
Cart
IT
Cart
Overbed
T bl
Ventilator
23’
gross
23’
gross
Ideal Room
397 nsf
Ideal Room
397 nsf
Balloon
Pump
Data Entry/
Access
TableDialysis
Machine
Hypothermia
Unit
Data Entry/
Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 31
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 31
18’
gross
18’
gross© HKS 2007

32. Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCM
Washington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHA
HKS Inc.
Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 32
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 32
Debajyoti Pati, PhD AIIA
HKS Inc.
Dallas, Texas

33. Demographics of ICU Care 1998g p
• 6,000 Adult ICUs
• 72,000 ICU beds
• 55,000 ICU patients/day
• 5,000,000 admissions per year
• 20,000,000 patient days per year
• Estimated expenditure $60-80 B/yr
• 8-10% of Hospital Beds
• 10-12 Avg. bed complement
• Mixed Med/Surg patient populations
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 33
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 33

34. The Team
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 34
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 34

35. Critical Care Team
• Intensivists • Respiratory Therapists
• Residents
• PAs/NPs
• Nutritionists
• Social WorkersPAs/NPs
• Bedside Nurses
• Nurse aides
Social Workers
• Clergy
• Others -Clerk PSAs• Nurse aides
• Senior nurses -
facilitator
• Others -Clerk, PSAs
• Quality, Utilization and
Risk Managementfacilitator
• Pharmacists
Risk Management
Personnel
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 35
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 35

36. An Intensivist
• A physician with the training and skills top y g
assess and manage patients with or who
are at risk for severe single or multi
t d f ti f di lsystem organ dysfunction from medical or
surgical illnesses or injuries
• Care provided from the earliest phases of
t d ti th h thacute decompensation through the
complex high risk periods of recovery
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 36
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 36

37. Critical Care Physicians
• Primary Specialtyy p y
• Subspecialty training
• Board certificationBoard certification
• “Intensivist model” – Leap Frog
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 37
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 37

38. Models of Care Unit Typesy
Closed
• Primary Attending = Critical Care Physician
Openp
• Primary Attending Not Always = Critical Care
• Often multi-organ system consultants without
a CC physician as the leader of a team
Transitional
• Any Primary Attending
• And an Intensivist Assumes Management
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 38
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 38
No Intensivist Availability

39. The C’s of Critical Care
• Patient CarePatient Care
• Collaboration
• Consistency - Continuity
C di i• Coordination
• CommunicationCommunication
• With Availability and Responsiveness
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 39
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 39

40. Programmatic Responsibilities
Mission
g
GoalGoalMission
– Effective patient care
– Mandates - Throughput
Customers
DemandDemand
GoalGoal
Customers
Resources SupplySupply
Organizational Structure
O ti l F t
Chain of CommandChain of Command
Operational Factors
– Mandates
– Constraints Coalescence …Coalescence …
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 40
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 40
– Processes

41. Patients and Providers
Demand: Patients Supply: Resources
– Quantity
– Quality
E t ti
pp y
– Providers
• Quantity – number,
commitment
– Expectations • Skills
• Personal expectations
– Clinical equipment and– Clinical equipment and
supplies
– Non clinical
accoutrementsaccoutrements
– Physical Infrastructure
(i.e. built environment)
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 41
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 41

42. Patient Populations
• Quantity - Baby Boomers – oldest turn 60y y
in 2006 at a rate of 7918/day
• ‘Quality’y
– Healthy but elderly
– Chronic Co-morbid factors
Ob it f ilt– Obesity, frailty
– Insults – new medical illnesses or exacerbations,
surgical procedures, trauma, complicationsg p p
• Expectations
• Surges – seasonal, biological, man
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 42
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 42
Surges seasonal, biological, man
induced

43. Patient Expectations
• Good outcome
• Safe
• ResponsiveResponsive
• Comfortable
• Information rich• Information rich
• Efficient
Family convenient (time and space)• Family convenient (time and space)
• Healing environment
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 43
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 43
• Minimum cost

44. Providers
• Youthful vs. Aged labor poolg p
• Availability – professional and personal satisfaction
and commitments
• Skill set development - OJT
• Expectations – personal amenities, restorativeExpectations personal amenities, restorative
and refreshment areas, communication devices,
conveniences (e.g. baby care, banks, laundry, grocery)
V i t• Variety – physician and nurse ‘extenders’, patient
and family services, utilization quality and risk
reviewers, supply chain, device maintenance, facility
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 44
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 44
pp y y
personnel

45. ‘Moveable’ Objects
• Clinical activities – monitors, testing equipment,
therapeutic devices, documentation and communication
technology, supplies (inc. medications)
• Non clinical accoutrements implements• Non clinical accoutrements – implements
related to waste, hygiene, ‘transition’ activities,
environment of care
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 45
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 45

46. Techno Evolution - Devices
• Sensor development • Devices – Monitoring
monitoring
• Communication devices
• Merge monitoring and
– Plug and Play
– Simplicity – set up, use,
take down
• Merge monitoring and
therapeutic modalities
• Electronic Medical Record
– Reliability
– Light weight – small size
– Wireless ?? tubeless
capture and display, task
management, transaction
processing
Wireless, ?? tubeless
– Voice control
– Data sharing (2 way)
• Positive ID
• Medication delivery
mass inventory pharmacy
• Devices – Testing
– Portable (e.g. sonography)
– Transportable
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 46
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 46
mass inventory pharmacy
unit beside nurse
(pharmacist) patient
a spo tab e

47. Devices Wars! (need title)
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 47
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 47

48. RemoDoc™
Pardon me,
may I cut in?
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 48
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 48
may I cut in?

49. Performance Expectations
• Patient preferencesp
• Superior results – Quality
• Efficient Use of Resources• Efficient Use of Resources
– Timely
E i l
Effectiveness
– Economical
– Resource conscious
(rationing)(rationing)
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 49
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 49

50. From Data to Orders
Recognition / Deducing / Concluding
HISTORY – TRENDS
Sufficient, accurate,
THINKING
Knowledge
Schooling’, Literature, Texts
Experience
, ,
timely data THINKING
‘Learned’ Expectations
DECISION
Clinical Conclusion - Assessment
WISDOM
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 50
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 50
Resources
Expectations
WISDOM

51. For Providers
• Education and Conference rooms
• Restorative atmosphere – personal / communal
• Nourishment facilitiesNourishment facilities
• Personal effects – ‘uniforms’, coats, purses
• Toilet/shower• Toilet/shower
• Communication devices
ADLs l d hild b ki i• ADLs – laundry, child care, grocery, banking, exercise
• Office
S
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 51
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 51
• Sleep

52. Familyy
• Information exchange
• Accommodations – waiting (inc. long and
short), nourishment, rest
• Mutual support
• Privacyacy
• Participation in care
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 52
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 52

53. Patients
• Bed features
• ‘Transition’ activities
• Reduced tethering• Reduced tethering
• Nourishment - food processing
• Physical therapy
• Environment
– Ceilings
– Day/night cycling – eyes, ears, positioning
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 53
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 53
ay/ g t cyc g eyes, ea s, pos t o g

54. Infection Control
• Susceptible patients • Infection Control – ICU
– Portals of entry into
patients
– Antibiotic usage and
– reservoirs, contamination
(structures and people)
• Aerosols and fomitesg
availability
– Immune compromise
• Aerosols and fomites
– Barriers
– Hand washing
• Hand cleansing
• Protective barriers
• Airborne isolation
– Protect other patients
P iti i l ti• Water
• Surfaces
• Positive pressure isolation
– Protect a single patient
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 54
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 54

55. Results!
• 12 m Baseline average VAP rate 16.33
• 12 m Project Average VAP rate 1 57 = 90% Reduction• 12 m Project Average VAP rate 1.57 = 90% Reduction
• 9 out of 12 months with zero VAP
Critical Care VAP Process/ Outcome
0%
100%
iance
20 00
25.00
30.00
35.00
Rate
Started PI
0%
50%
Compli
0.00
5.00
10.00
15.00
20.00
VAPR
F-
04
M-
04
A-
04
M-
04
J-
04
J-
04
A-
04
S-
04
O-
04
N-
04
D-
04
J-
05
F-
05
M-
05
A-
05
M-
05
J-
05
J-
05
A-
05
S-
05
O-
05
Vent Bundle Compliance 0% 0% 0% 0% 0% 0% 0% 16% 40%50% 100 100 100 100 100 96% 100 100 100 96% 100
Critical Care VAP Rate 12.6 33.518.6 25.317.5 5.055.99 16.3 5.856.25 0.000.00 0.000.00 10.8 7.140.00 0.000.00 0.000.00
VAP Cases 2 5 3 4 4 1 1 3 1 1 0 0 0 0 2 1 0 0 0 0 0
04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05 05 05 05 05
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 55
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 55
VAP Cases

56. Equipment and Supplies
• Storageg
• Accessibility
• CompatibilityCompatibility
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 56
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 56

57. Equipment and Supplies
Increases in
monitoring,
pumps, and
equipment
requirements
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 57
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 57

58. Patient Rooms
• Occupants • Over bed tablesp
– Patient
– Family
– Staff
• Restraints
• Back walls– Staff
• Sitting
• Documentation
• Furniture
• Documentation centers• Documentation
• Circulation
• Cabling
Documentation centers
• Cabling
• Reaching
Comm nication
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 58
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 58
• Communication
– TV, Radio, Computer

59. © HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 59
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 59
Royal Alexandra Hospital - Edmonton, Alberta WSAG Architects

60. Environmental Factors
• Visual • Temperature
• Auditory
• Tactile
p
• Chemical
– including humidity
• Tactile
• Olfactory
• Particulate
• Electromagnetic
• Gustatory
• Spatial
ec o ag e c
p
• Familiar – cultural, ethnic, personal
• Unfamiliar psychosomatic interplay
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 60
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 60
• Unfamiliar – psychosomatic interplay

61. Environment of Care Continuum
EnrichingEnriching
Encouraging
HealingHealing
Helpful
SoothingSoothing
Neutral
Irritatingtat g
Noxious
Dangerous’
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 61
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 61
g
Hurtful

62. Entrance Hallway?y
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 62
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 62

63. The Soda Machine?
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 63
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 63

64. Resource Constraints
• Labor shortage and retention – RNs,
MDs, therapists, pharmacists, technicians
• EMRs – underdeveloped and installed
• Physical infrastructure
• Capacity
• Sq. Feet / ICU
• Adjacencies
• Capital
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 64
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 64

65. Need Title
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 65
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 65

66. Constraining Forces
• Confines of real estate
• Renovation projects
• Capital limitationsCapital limitations
• Minimum standards mind set
• Ineffective Clinical/Design professional• Ineffective Clinical/Design professional
dialogue
• Paucity of research and its application• Paucity of research and its application
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 66
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 66

67. Maslow’s Hierarchy of Needs
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 67
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 67

68. Title Needed
• Functional Programg
– Programmatic Missions Needs ~ Acuity
– Throughput – Contingency surges
Ri k ( )– Risk (e.g. age)
– Physical characteristics (e.g. obesity)
– Operational paradigmsOperational paradigms
– Future directions
• ‘Minimum’ Standards/Guidelines
– Level I
– Level II
L l III
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 68
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 68
– Level III

69. ‘Minimum’ Standards
• ‘Code’ – Guidelines for Design and Construction of
Health Care Facilities, NFPA
• Resources – real estate, capital
Functional program i i• Functional program – mission
• Patient vs./and Provider needs
• Provider availability• Provider availability
• Environment of Care – hierarchy of needs
• Patient and provider expectations• Patient and provider expectations
• Safety, longevity
• Societal – environmental sensitivity
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 69
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 69
Societal environmental sensitivity
• Surge

70. Title Needed
bil t t f t f b d
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 70
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 70
mobile system at foot of bed
CVICU, Methodist Hospital – Houston, Texas WHR Architects

71. Evolving Trends - Novel Ideasg
• Obesity, age, acuityy, g , y
• Design to augment staff effectiveness and
retentionretention
• ‘Environment of care’
• Telemedicine – eICU
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 71
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 71

72. Evolving Trends - Novel Ideasg
• Move tests to the ICU
• Laboratory - portable analyzers
? R di l i d h– ? Radiologic procedures – e. g. sonography
• EMR (Acquiring) Pattern
(Recognition/Deducing/Concluding) plus
electronic process management tools
• Sensitivity to our environment
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 72
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 72

73. Future - Predictions
• Demand/Labor Resource mismatch
– Labor imperatives – professional and
personal decisionspersonal decisions
• Regionalization – ICU Certification
• Team
– Composition – midlevel practitioners
– ‘Model’ evolution - O/P I/P specialists -
hospitalists
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 73
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 73
p

74. Future - Predictions
• Expanded prescriptive authorityp p p y
• Family participation
• Other resources limitationsOther resources limitations
– medications, blood products
• Telemetry in the ICUTelemetry in the ICU
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 74
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 74

75. Future - Predictions
• Marriage of monitoring and therapeuticMarriage of monitoring and therapeutic
devices
• Complication prevention methodologies
• Organ based dysfunctional metabolismOrgan based dysfunctional metabolism
measurements and interventions
End organ perfusion monitoring- End organ perfusion monitoring
• Genetic profiling
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 75
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 75
• Simulation

76. Suggestions
• More robust clinician/user participation inp p
design planning
• Translate research into designTranslate research into design
– Research into Learned Design
Evidence Based Design– Evidence Based Design
• National POE database
• Research
• Write a proposal
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 76
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 76

77. Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCM
Washington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHA
HKS Inc.
Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 77
ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 77
Debajyoti Pati, PhD AIIA
HKS Inc.
Dallas, Texas